PANCREATITIS.
DR. P.C. Mishra,MD.
ACUTEPANCREATITIS.
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? An acute condition presenting with abdominal
pain usually associated with raised
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blood/urine pancreatic enzyme as a result ofpancreatic inflammation.
? Reversible pancreatic parenchymal injury
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associated with inflammation.
ACUTE PANCREATITIS.
? PATHOPHYSIOLOGY?
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? Premature activation ofpancreatic enzymes within the pancreas.
? Anything that injures the acinar cells and impairs
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the secretion of zymogen granules or damages
the duct epithelium and thus delays enzymatic
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secretion , can trigger acute pancreatitis.? Once cellular injury has been initiated , the
inflammatory process can lead to pancreatic
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oedema, haemorrhage, and eventually necrosis.
ETIOLOGY.
? acute pancreatitis-
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? As an acute inflammatory process of thepancreas with variable involvement of other regional
tissues or remote organ system.
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? Two major causes are--
? Biliary calculi(50-70%)
? Alcohol abuse (25%).
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? The remaining causes may be idiopathic or rare.? Approx. 25 % cases of Acute pancreatitis.
? Act by increasing the synthesis of enzymes by
pancreatic acinar cells.
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? Over-sensitization of acini to cholecystokinin.
? SMOKING-
? cigarette smoking is an independent
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risk factor for acute and chronic pancreatitis.HYPERTRIGLYCERIDEMIA.
? Serum concentration above 1000 mg/dl ppt. Attacks of
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acute pancreatitis.? A triglyceride level higher than 2000 mg/dl confirm the
diagnosis of acute pancreatitis.
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? Hypercalcemia-
Hypercalcemia of any cause can lead to acute
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pancreatitis.? Deposition of calcium in the pancreatic duct and calcium
activation of trypsinogen within the pancreatic parenchyma.
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Causes of Acute pancreatitis.? Gall stone.
? Alcoholism.
? Abdominal trauma.
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? Hyperparathyroidism.? Hypercalcaemia.
? Autoimmune pancreatitis.
? Viral infection.
Gall stone pancreatitis.
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? Transient blockage of common bile duct--
reflux of bile into pancreatic duct and impair
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flow of normal pancreatic juice ?prematureactivation of pancreatic enzymes within duct
system.
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CLINICALLY.? Presenting with 2 of the following 3 criteria
? Epigastric pain consistent with pancreatitis.
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? Serum amylase or lipase level greater than 3
times the upper limit of normal.
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? Radiologic imaging consistent with pancreatitis(
usually CT or MRI ).
HISTORY TAKING.
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? 1.Abdominal pain-
? Site-Diffuse,upperabdominalpain.
? Onset--sudden.
? Character?Boringpain.
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? Radiation---Radiatetoback.? Associatedfactor-Nausea,vomiting...
? Timing--Painescalatesinintensityandpeakswithin
10-20minutesofonset.
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? Elevationoftemperatureisoftenisacute
pancreatitis.
Abdominal Examination.
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? 1.Inspection-- abdominal distension.
? 2.Palpation--
? Hepatomegally.
? Tenderness.
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? Cullen sign.(Bluediscoloration around umblicus)
? Gray turner sign. ( Blue red
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purple discoloration around flank).
? Peritoneal sign
? Rigidity and Guarding.
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? Percussion--? Dullness suggesting ascites.
Auscultaion-
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? ascultate the abdomen for hypoactiveor an absent bowel sound.
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INVESTIGATION.
? Biochemical---
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? Serum Amylase increase 3x thannormal or more than 1000IU/mL.( Peak within
the first 24 hrs after onset of symptom.
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? Serum lipase has longer half life thus more
useful in delayed case.
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? Serum lipase: more sensitive and specific forpancreatitis than Amylase.
Amylase and Lipase.
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? Elevated serum amylase and Lipase levels incombination with severe abdominal pain. Often
trigger the initial diagnosis of acute pancreatitis.
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? Serum lipase rises 4 to 8 hrs from the onset of
symptoms and normalise within 7 to 14 days
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after treatment.? Marked elevation of serum amylase level during
24 hrs.
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? If lipase level is about 2.5 to 3 times that of
Amylase, it is an indication of pancreatitis due to
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Alcohol or gall stone.Biochemical investigation.
? Serum amylase-
? Levels turn normal after 48-72 hrs even
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with the continuing of pancreatitis, serum lipase should be sent
that remains high for 7-14 days.
? Persistent elevation suggests pseudocyst,
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pancreatic abscess or non pancreatic
cause(intestinal obstruction, mumps,narcotics).
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? Serum lipase- Remains elevated for 7-14 days. It is diagnostic.Serum Lipase.
? The sensitivity of serum lipase is similar to that
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of serum Amylase and is between 85% to100%.
? Lipase may have greater specificity for
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pancreatitis than amylase.
? Serum lipase always is elevated on the first
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day of illness and remains elevated longerthan does the serum amylase.
Other laboratory Findings.
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WBC- 15000----30OOOLeucocytosis
GLUCOSE HIGH
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Hyperglycemia in severe cases.BUN MAY BE ELEVATED
SERUM CALCIUM MAY BE LOW IN 25% OF CASES.
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AST,BILIRUBIN,ALP ARE TRANSIENTLY ELEVATED,ALBUMIN IS LOW IN10% OF CASES AND INDICATE SEVERE PANCREATITIS
ELEVATED LDH SUGGEST POOR PROGNOSIS
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and indicate biliary tract disease.Assesment of C-reactive Good indicator of progress.
ABG shows HYPOXIA.
Other cause of increased serum
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Amylase.
? Renal failure.
? Liver cirrhosis.
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? Peritonitis.? Ruptured ectopic pregnancy.
? Salivary gland inflammation(parotitis).
other blood test.
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FULL BLOOD COUNTElevated Leucocyte count for Ranson's
criteria and to predict prognosis.
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LFT
To asses cause of pancreatitis/obstructive
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jaundice.Random blood glucose
Damage to beta cells interferes with insulin
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production causing Hyperglycemia( in severe
cases).
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Serum calciumHypocalcaemia suggest saponification.
Ranson score
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predicting the severity of acute pancreatitis.? At admission
. age in years > 55
? WBC count > 16000 cells/mm3.
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? Blood glucose > 200 mg/dl? Serum AST > 250 IU/L
? Serum LDH > 350 IU/L
? At 48 hrs
? Calcium- < 8 mg/dl
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? Hypoxia (po2 < 60mmHg)? Increased BUN
IMAGING ?ULTRASOUND.
? USG should be performed within 24 hrs in all
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patient.
? To detect--- Gallstones.
? To rule out-- Acute Cholecystitis.
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? To determine whether the common bile ductis dilated.
? To evaluate change on pancreas i.e. Edema.
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Mass in pancreas.
CT SCAN.
? Not neccessary for all patients.
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? May reveal pseudocyst orabscess.(complication of acute pancreatitis).
? CT Findings--
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? significant swelling andinflammation of the pancreas.
Management Acute pancreatitis.
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? Mild Acute pancreatitis--? 1.Nill by mouth.
? 2.Fluid resuscitation-4 pint.
? 3.Analgesia-IM Tramal 50mg TDS.
? 4.Treat underlying cause.
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? 5. NO role of antibiotic.Severe Acute Pancreatitis.
? Admission to ICU.
? Oxygen supplementation.
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? Analgesia.? Aggressive fluid rehydration.
? Monitor vital sign.
? Monitor haematological and biochemical
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parameters.? Nasogastric drainage.
? Antibiotic prophylaxis--imipenem, cefuroxime.
CASE 1.
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? 56-years-old obese man who is in cardio-
respiratory distress. While reviewing the
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patients record you see that he has a four-yrsh/o alcohol abuse and he was admitted to the
hospital via the emergency room 36 hrs
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previously with a two day h/o Epigastric pain
and vomiting.........
On admission vital sign..
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? Blood pressure-------95/30
? Pulse rate -------110/min
? Respiratory rate -----28 breath/min.
? temp. ------38.6
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? Abdomen was distended and diffusely tender.? No Bowel sound were heard.
Laboratory data included:
? WBC count----18,000/ml
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? Blood glucose---220 mg/dl? Calcium -------- 7 mg/dl
? Creatinine -----2 mg/dl
? LDH -----980 IU/l
? CRP ------15 mg/dl
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? Amylase ---180 IU/l? Lipase 1540 IU/l
? The serum was Lipemic.